Knowledge and attitude toward the practice of circular economy in conjunction with biomedical waste management among dental practitioners and technicians in Belagavi, India

Study design

This study used an observational, cross-sectional study design and was performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines.

Study setting

It was conducted among faculty, postgraduates, interns, clinical undergraduates(3^rd and 4^thyear of study), and technicians of two dental colleges located in the Belagavi district of Karnataka state. These groups provided dental care and handled patient care materials at the clinics and laboratories. This survey was performed between April and May of 2022.

Eligibility criteria

The study included all the participants from the two dental colleges who were willing to give informed consent. Those who were not willing to give consent for the study were excluded (Figure 1).

Close

Figure 1:

Study enrolment Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) flowchart.

Export to PPT

Questionnaire validation

A pilot study was conducted on a representative sample consisting of 10 participants from each group to detect any design flaws such as word ambiguity, inability to understand the questions, and other questionnaire-related errors. The questionnaire’s reliability was deduced to be 0.85 using Cronbach’s α, and its validity was deduced using face validity (84%) and content validity ratio (0.78). Based on the pretest feedback, the questionnaire was further refined by additions and deletions to make it more appropriate and specific to the purpose of the study, and thus a valid questionnaire was designed.

Questionnaire characteristics

The self-administrated questionnaire included 23 close-ended questions in English, 12 of which were knowledge based and 11 of which were attitude based. The questionnaires were distributed to the participants during the working hours of the two dental colleges. Participants were instructed to attempt all the questions in 15 minutes. The first section of the questionnaire consisting general sociodemographic information about the participant, which was used for qualitative analysis, and the second section covered multiple elements of circular economy.

Bias

The questionnaire was administered by a single investigator in a classroom setting on a specified date and time. To mitigate potential bias, the process was closely supervised by volunteers, ensuring unbiased completion of the questionnaire. This approach helped maintain the integrity of the responses as participants were not influenced by other individuals in the classroom.

Sample size estimation and sample distribution

From the pilot study, the minimum sample size was estimated to be 568 with type I (α) error= 0.05 and power (1–β) = 0.95 using G^*Power statistical software (Ver. 3.1.9.4.). The list of participants belonging to various affiliations from the two dental colleges in Belagavi was obtained. All the participants were recruited from the list by simple random sampling. Hence, a total sample size of 640 was obtained.

Statistical analysis

Collected data were entered in Microsoft Excel 2019 and analyzed using IBM-SPSS Statistics, Version 21 (United States). Descriptive statistics were computed, which included percentages, means, and standard deviations. The normality of the data distribution was determined using the Kolmogorov–Smirnov test and the data was found to be normally distributed. Chi-square test was used to check for the association between the study variables among the participants. Analysis of variance (ANOVA) test was performed to check for any significant differences in the study parameters. Multiple linear regression analysis was also performed. For all the tests, confidence level and level of significance were set at 95 and 5%, respectively. The knowledge scores were categorized into high (> 8 score/> 80^th percentile), medium (4–8 score/40^th– 80^th percentile), and low (< 4 score/< 40^th percentile) and the attitude scores into positive (> 6 score/> 50th percentile) and negative (≤ 6 score/≤ 50^th percentile).^[14]

Knowledge about circular economy

Majority of participants had low (74.5%) followed by medium (24.1%) and high (1.4%) knowledge score. Figure 2 illustrates the violin plot comparing the kernel density estimate of the knowledge scores in percentile among the study participants. The ANOVA test showed that there was a significant difference in the knowledge scores among the five study groups (p < 0.001); similarly, the ANOVA test depicted that there was a significant difference (p < 0.001) in the knowledge scores among the participants of different age groups (20–30, 31–40, > 40). The mean overall knowledge score was highest among dental faculty (5.28 ± 1.53) and the least among dental technicians (1.88 ± 0.84) (Table 3).

Close

Figure 2:

Comparison of knowledge score in percentile among dental postgraduates and faculty on circular economy. Knowledge score indicators: low (< 40^th percentile), medium (40^th–80^th percentile), and high (> 80^th percentile). The statistical test used: analysis of variance (ANOVA); level of significance: ^*p ≤ 0.05 is considered statistically significant.

Export to PPT

Attitude toward circular economy

Majority (79.4%) of the study participants had a positive attitude and 20.6% participants had a negative attitude toward circular economy. Figure 3 illustrates the violin plot comparing the kernel density estimate of the attitude scores in percentile among the study participants. The ANOVA test showed that there was a significant difference in the attitude scores among the five study groups (p < 0.001); similarly, the ANOVA test depicted that there was a significant difference (p = 0.026) in the attitude scores among the participants of different age groups (20–30, 31–40, > 40). The mean overall attitude score was highest among dental interns (9.10 ± 1.33) and the least among dental technicians (7.50 ± 1.84) (Table 3).

Close

Figure 3:

Comparison of attitude score in percentile among dental postgraduates and faculty toward circular economy. Attitude score indicators: negative (≤ 50^th percentile) and positive (> 50^th percentile). The statistical test used: analysis of variance (ANOVA); level of significance: ^*p ≤ 0.05 is considered statistically significant.

Export to PPT

Relationship between study variables using pearson’s correlation coefficient

A positive linear correlation (r = þ0.257) was seen between the knowledge and attitude scores that was statistically significant (p < 0.001) using Pearson’s correlation coefficient test. The field-wise correlation data are presented in Table 4.

Association between demographic variables and knowledge/attitude scores using multiple linear regression

Multiple linear regression analysis depicted a significant relationship between knowledge of the participants and their age (p < 0.001, R= 0.223) and affiliation (P < 0.001, R = 0.601). The attitude of the participants showed significant relationship with affiliation (p < 0.001, R = 0.334). The dependence of knowledge and attitude on the variables, including age, gender, and affiliation, were found to be 46.1 and 11.6%, respectively (Table 5).

Awareness about circular economy

The Ellen MacArthur Foundation has outlined three main principles for describing the philosophy behind circular economy and they are to eliminate waste and pollution, circulate products and materials, and regenerate nature (Figure 4).^[19] Only 37.2% participants were aware of the three R’s philosophy (reduce, reuse, and recycle) of waste management. The National Institution for Transforming India (NITI Aayog), India’s apex public policy body, advocates Aatmanirbhar Bharat (self-reliant India) by implementing circular economy to generate significant annual benefits while reducing congestion and pollution. Eleven committees have been established to expedite the country’s transition from a linear to a circular economy.^[20] Majority (72.5%) of the participants in this study were unfamiliar with the term circular economy, and 92.7% were unaware of the country’s adoption of the circular economy model for self-sufficiency. Majority (98.9%) of them desired explicit training in circular economy principles, while 99.4% advocated that concepts of circular economy should be introduced in undergraduate and postgraduate curriculums and 98.9% expressed that there is a need for a public policy on circular economy. The participants predominantly (79.2%) felt that the COViD-19 pandemic has aggravated the need for adopting an efficient circular economy model. This can be correlated with the findings from the study by Mariam et al,^[21] where 88.65% participants were of the opinion that the pandemic has increased financial burden on BMWM.

Close

Figure 4:

Key differences between (A) linear economy and (B) circular economy given by AkzoNobel (2015).

Export to PPT

Reduce, reuse, and recycle philosophy

BMW is frequently disposed through incineration and landfilling in developing countries like India.4 When BMW ash from incineration is disposed by landfilling there is a greater risk of groundwater contamination due to metal leaching. Additionally, there is the issue of scarcity of space and high cost for land disposal. It meant that the most sustainable way to use BMW ash was in agriculture as fertilizer and in the construction sector to ensure minimal metal leaching.^[12] Majority (63.3%) of the participants were aware of this sustainable mode of BMW ash disposal. In dental practice one of the most commonly used instruments is a syringe and in India majority of the clinicians preferred a disposable one. In the current study, 81.9% participants believed that disposable/single-use products in dentistry do not contribute to circular economy and 78% preferred to use nondisposable metallic syringe. A metallic syringe generates less waste but creates an inconvenience of autoclaving after every use. The energy spent for autoclaving is a factor to be considered. According to Unger and Landis’ comparative lifecycle assessment, one reusable dental bur can be used for a maximum of 30 instances and only 17.8% participants were aware of the same. It was also revealed that only 32.8% study participants were aware that when ultrasonic and autoclave loads were optimized, reusable burs had a 40% lower environmental impact than disposable burs.^[12,22]

Plastic waste packaging that comes along with dental products accounts for the large chunk of waste that is generated. In this study, 74.5% study participants were aware that plastic packaging can be recycled, on the contrary 52.3% were not aware of the amount of garbage (33%) generated from a product’s waste packaging. Similarly, 88.3% participants believed that manufactures should cut down on the packaging of the dental products and 61.9% preferred to use products with biodegradable packaging that is relatively expensive. From this it can be interpreted that manufactures can use packaging that may marginally increase the overall cost of the product but causes minimal damage to the environment. They can think of materials such as nanocellulose as an alternative to plastic packaging.^[23] Shipping charges can be reduced by purchasing often-used dental products in bulk. It can lower the usage of fuel and waste packaging needed for shipping. In this study, 65.2% participants believed in ordering the shipments in bulk. Increasing the shelf life of some of these products could prove to be beneficial as this will reduce the need for multiple shipments.^[12] Dental care facilities and laboratories generate wastewater containing silver thiosulfate from the X-ray fixer solution and use impression materials like polyvinyl siloxane and polyethers. The toxic byproducts from these materials are leached into the environment creating a major source of environmental pollution.^[13] A study by Al Mortadi et al revealed the unsatisfactory practices of dental laboratory technicians in impression disinfection, increasing the chance of cross-infection.^[24] Majority (94.4%) of the participants in this study preferred using digital imaging techniques. This emphasizes that digital solutions for imaging and impression of oral structures should be fully integrated into dental care facilities and laboratories to completely replace the conventional methods.^[12]

Achieving sustainability through regulations and monitoring

International Organization for Standardization (ISO) 14001 is a globally recognized standard that specifies the requirements for an environmental management system. It assists companies of all sizes and sectors in making their day-to-day operations more sustainable. Majority of the participants (79.2%) in this study were not aware of ISO 14001, an internationally accepted accreditation. Health care sector accounts for 5% of the global carbon emissions, therefore it is essential for manufactures to cut down on the carbon footprint of their dental products. Majority (94.1%) of the study participants preferred that the BMW to be further segregated according to their carbon footprint. In contrast, half (50.2%) of the participants opted to use products with a higher carbon footprint that can cut short the treatment time. Perhaps more awareness on carbon emissions and their negative effects on the environment should be disseminated among this population. A possible solution could be the use of electronic health records and dashboards that include data on emissions which facilitates decision making to reduce carbon footprint at dental care facilities.^[25]

The study participants had an overall favorable attitude toward circular economy but the knowledge on circular economy was found to be moderate to low. Dental professionals and laboratory technicians should comprehend the value of effective BMWM and its implications on public health.^[26] A study conducted by Parida et al among other health care workers (HCWs) also reported inadequate knowledge on BMWM. This existing knowledge gap among the HCW on BMWM must be filled along with the incorporation of principles of circular economy.^[27] This study recognizes an opportunity to significantly broaden the reach of the importance of circular economy among dental institutions to promote sustainability. Hence, dissemination of knowledge, adoption of sustainable services guidelines, and effective management of resources in dental care facilities and laboratories is required. They should strive to align themselves with the nation’s sustainable developmental goals and be trained in BMWM that is more suitable for the current scenario. As part of their training, routine monitoring and supervision and special inputs in enhancing the existing BMW treatment modalities at the community level should be stressed. Furthermore, there is a need to assist other organizations working toward circular economy, as individual action may not be successful, and collective effort is required, given the importance of this issue to public health.

This study was limited to one region of the country due to the restrictions imposed by the global pandemic. Perhaps a large-scale study, across different dental institutions and laboratories in other parts of the country will give an overall outlook on circular economy.